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When antithrombotic drugs encounter cerebral hemorrhage, teach you calmly!

 Last Update: 2021-07-30
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Antithrombotic drugs are commonly used clinically.
Bleeding is the most common complication.
A small amount of bleeding or bleeding in non-important parts usually has a good prognosis through symptomatic treatment.
However, intracranial hemorrhage, as a bleeding in important parts, can often cause disability or even fatal
.

It is reported in the literature that 12-14% of intraparenchymal hemorrhage is related to anticoagulant drugs.

Antithrombotic drugs are commonly used clinically.
Bleeding is the most common complication.

Diagnosis and evaluation

The patient's vital signs (such as consciousness disturbance, pupil changes, cranial nerve symptoms, focal neurological impairment symptoms, pathological signs, etc.

2.
Imaging Evaluation

CT examination is the gold standard for diagnosing early cerebral hemorrhage
.

3.
Bleeding volume assessment

Hematoma volume=0.
5*maximum area long axis cm*maximum area short axis cm*number of slices, scanning slice thickness 1cm
.

Hematoma volume=0.

2.
Medical treatment

2.
Medical treatment 2.
Medical treatment

1.
Withdrawal

① The amount of cerebral hemorrhage is large, which causes the patient's vital signs to be disordered or is assessed to have a great risk of death .
Antithrombotic drugs should be stopped immediately
.

②The amount of cerebral hemorrhage is large , causing new neurological damage, and it is very likely to cause disability of the patient .
Antithrombotic drugs should be stopped immediately
.

③Although there is new cerebral hemorrhage , it has little effect on the general condition of the patient; or only new blood is found on imaging, which has little effect on the prognosis and is at high risk of ischemic events.
The drug should be discontinued immediately.
7 After -10 days, consider resuming antiplatelet therapy
.

The type or dosage of antiplatelet drugs can also be appropriately reduced according to the condition, and bleeding should be closely monitored

③Although there is new cerebral hemorrhage , it has little impact on the general condition of the patient; or only new blood is found on imaging, which has little effect on the prognosis and is at high risk of ischemic events.

When a patient has cerebral hemorrhage, reversing the effect of antithrombotic drugs may be the key to hemostasis
.

Note: Vitamin K antagonists are not recommended for the following two situations : A.
It is highly suspected that cerebral hemorrhage is caused by intracranial venous sinus thrombosis , and it is not recommended to antagonize VKA; B.
When cerebral hemorrhage patients have symptomatic or life-threatening thrombosis, When ischemia, heparin-mediated thrombocytopenia or DIC
.

Note: Vitamin K antagonists are not recommended for the following two situations.
Note: Vitamin K antagonists are not recommended for the following two situations : A.
It is highly suspected that intracranial venous sinus thrombosis may cause cerebral hemorrhage, and it is not recommended to antagonize VKA; B.
When brain Bleeding patients with symptomatic or life-threatening thrombosis, ischemia, heparin-mediated thrombocytopenia, or DIC
.
thrombus

3.
Other hemostatic drugs

①For patients with active bleeding and platelet count <50×10 ⁹ /L, platelets can be transfused ; for patients with fibrinogen concentration <1g/L or activated partial prothrombin time (international standardization ratio)>1.
5 times the normal value , Can be given fresh frozen plasma
.

①For patients with active bleeding and platelet count <50×10 ⁹ /L, platelets can be transfused ⁹; for fibrinogen concentration <1g/L or activated partial prothrombin time (international standardization ratio)>1.
5 times the normal value Patients can be given fresh frozen plasma
.

②Sulfenac : This product can constrict blood vessels , reduce capillary permeability, enhance platelet aggregation and adhesion, shorten clotting time, and achieve hemostasis
.
It is clinically used to prevent and treat bleeding before and after various operations, or for bleeding caused by poor platelet function and increased vascular fragility
.

③Hemagglutinin : It can be used to reduce bleeding or stop bleeding; it can also be used to prevent bleeding
.
It can be injected intravenously, intramuscularly or subcutaneously, or locally
.
Because it effectively degrades fibrinogen into fibrin, it should not be used continuously for more than 7 days
.

④Antifibrinolytic drugs: competitively inhibit plasminogen hydrolysis, mainly used for bleeding caused by hyperfibrinolysis or excessive primary fibrinolytic activity.
Currently commonly used antifibrinolytic drugs include aminocaproic acid and tranexamic acid Acid and amino toluic acid
.

Generally adult 0.
25-0.
5g/time IV, if necessary, 1-2g/day, 1-2 times administration
.

4.
Other medical treatments

①Blood pressure management : For patients with cerebral hemorrhage with systolic blood pressure of 150-220 mmHg, it is safe to reduce blood pressure to 130-140 mmHg within a few hours without acute blood pressure contraindications; for cerebral hemorrhage with systolic blood pressure> 220 mmHg In patients, the target systolic blood pressure is 160 mmHg
.
During treatment, monitor blood pressure every 5-15 mi to avoid blood pressure fluctuations
.

① blood pressure management Management : systolic blood pressure 150-220 mmHg for patients with cerebral hemorrhage, acute blood pressure in the absence of contraindications, the step-down within hours to 130-140 mmHg are safe; for systolic blood pressure> 220 mmHg brain In bleeding patients, the target systolic blood pressure is 160 mmHg
.
During treatment, monitor blood pressure every 5-15 mi to avoid blood pressure fluctuations
.

②Glucose management : control the blood glucose level at 7.
8-10.
0 mmol/L, and give insulin treatment if necessary
.

③Body temperature management : central fever may occur in the early stage, especially those with massive cerebral hemorrhage, thalamic hemorrhage or brainstem hemorrhage
.
Three days after the onset, the patient may have fever due to infection and other reasons, and should be differentiated and treated symptomatically
.

④Intracranial hypertension drug treatment : moderately raise the head of the bed, sedation and analgesia, give mannitol, hypertonic saline, furosemide, glycerol fructose and albumin dehydration to lower intracranial pressure
.
For patients with hydrocephalus with disturbance of consciousness, ventricular drainage can be used to relieve the increase in intracranial pressure
.

⑤ seizures : not recommended prophylactic use of anti- epileptic drugs
.
Authors suspected of having epilepsy should consider continuous EEG monitoring
.
Patients with clinical seizures or EEG epileptic discharges should be treated with antiepileptic drugs
.

⑥Prevention and treatment of deep vein thrombosis and pulmonary embolism : D-dimer detection and limb Doppler ultrasonography can be performed on suspected patients; patients are encouraged to move as soon as possible and raise their legs; avoid intravenous infusions of the lower extremities, especially the paralyzed limbs; paralysis Patients should use pneumatic pump devices to prevent DVT as soon as possible; compression stockings are not recommended to prevent DVT; for high-risk patients who are prone to deep vein thrombosis (excluding patients with cerebral hemorrhage caused by coagulation dysfunction), after the hematoma is stable, consider subcutaneously 1-4 days after the onset Inject low-dose low-molecular-weight heparin or unfractionated heparin to prevent DVT, but attention should be paid to the risk of bleeding; when patients have symptoms of deep vein thrombosis or pulmonary embolism, systemic anticoagulation therapy or inferior vena cava filter implantation can be used
.

3.
Surgical treatment

3.
Surgical treatment 3.
Surgical treatment

Choose a reasonable surgical method according to the patient's condition
.
Patients with cerebral hemorrhage with supratentorial hemorrhage ≥30ml and subtentorial hemorrhage ≥10ml have any one of the following, which is an absolute indication for surgery: The midline structure of the brain is displaced ≥1 cm; The fourth ventricle needs more attention; there are bilateral pupils with unequal large pupils, delayed pupil light reflection, and even dilated pupils, and disappeared reflections; the patient has a worsening state of consciousness, such as restlessness, lethargy, or even coma
.

For patients with drowsiness or light coma, drugs for lowering intracranial pressure can be given first, and anticoagulant drugs can be stopped for 1 week before surgery
.
Conscious patients, if they have neurological dysfunction, can undergo hematoma puncture treatment or stereotactic intracranial hematoma removal one week after stopping anticoagulant drugs
.

During the perioperative period, platelet function and coagulation function should be monitored, and platelet transfusion should be performed when necessary
.

Fourth, restart antithrombotic therapy

Fourth, restart antithrombotic therapy Fourth, restart antithrombotic therapy

When can the anticoagulation therapy be restarted after intracranial hemorrhage caused by oral anticoagulation drugs? There is currently a lack of relevant research evidence
.

1.
Timing of resuming anticoagulation therapy: ①For patients with atrial fibrillation and deep vein thrombosis, it is recommended to consider resuming preoperative anticoagulants after 4 weeks after surgery to prevent recurrence of cerebral hemorrhage
.
②For patients with pulmonary embolism after prosthetic mechanical valve replacement and the indication for anticoagulation, it is a high-risk factor for thromboembolic events, and the anticoagulant before surgery can be considered 2 weeks after surgery
.

2.
Timing of resuming antiplatelet therapy: ①For patients within 6 months after coronary stent placement, antiplatelet drugs are essential to prevent stent thrombosis.
Therefore, antiplatelet drugs should be restored as soon as possible after the imaging examination confirms that there is no hematoma enlargement.
Platelet therapy is recommended not to exceed 1 week at the latest
.
If cerebral hemorrhage occurs more than 6 months after stent placement, the time to resume antiplatelet drugs can be postponed appropriately, and can be postponed to 2 weeks at the latest
.
②For patients undergoing primary prevention of atherosclerotic thrombosis, discontinuing antiplatelet drugs does not significantly increase the risk of ischemic stroke, and can be delayed until 2 weeks after bleeding before resuming medication
.
③For patients who prevent peripheral arterial thrombosis, even if the disease progresses after stopping the antiplatelet drugs, there is no life-threatening risk, and the medication can be postponed until 2 weeks after bleeding
.
④For high-risk patients with deep vein thrombosis, anticoagulant drugs are routinely recommended for prevention, and antiplatelet drugs are not recommended for prevention
.

Emphasize : The condition of patients with antithrombotic therapy combined with cerebral hemorrhage is complex, and multidisciplinary cooperation may be required to formulate individualized treatment
.
Before restarting antithrombotic therapy for such patients, the patients and their families should be informed repeatedly of the risk of cerebral hemorrhage
.

He stressed stressed : antithrombotic therapy complicated with cerebral hemorrhage patient's condition may require a multidisciplinary collaboration to develop individualized treatment
.
Before restarting antithrombotic therapy for such patients, the patients and their families should be informed repeatedly of the risk of cerebral hemorrhage
.

Summarize

Summary summary

Before antithrombotic therapy, the risk of cerebral hemorrhage should be fully assessed.
For patients with previous cerebral hemorrhage or refractory hypertension, antithrombotic programs should be carefully formulated and blood pressure should be closely monitored
.
Once cerebral hemorrhage occurs, neurology, neurosurgery, etc.
should be combined as soon as possible to assess the severity of the patient's condition.
Cardiology and neurologists should jointly formulate hemorrhage treatment and antithrombotic treatment plans to improve patient survival and improve prognosis
.

references:

1.
Guidelines for the Reversal of Antithrombotic Drugs in Patients with Intracranial Hemorrhage A statement from the American Society of Neuro Intensive Care and the American Society of Critical Care Medicine Medical and Health Professionals "International Journal of Cerebrovascular Diseases" 2016, Volume 24, Issue 11, 961-985

2.
Chinese Expert Consensus on the Perioperative Management of Neurosurgery in Patients with Intracranial Hemorrhage in the Treatment of Antithrombotic Drugs (2018 Edition) Chinese Medical Journal 2018, Vol.
98, No.
21, 1640-1645.

3.
Multidisciplinary Expert Consensus on Antithrombotic Treatment of Acute Coronary Syndrome Combined with Hemorrhage Prevention and Treatment "Chinese Journal of Internal Medicine" 2016, Volume 55, Issue 10, pp 813-824

4.
Expert consensus on the emergency treatment of non-traumatic hemorrhage "Chinese Journal of Emergency Medicine" August 2017, Volume 26, Issue 8, Page 850-856

5.
Guidelines for Diagnosis and Treatment of Cerebral Hemorrhage in China (2019) "Chinese Journal of Neurology" 2019, Volume 52, Issue 12, Pages 994-1005

5.
Guidelines for Diagnosis and Treatment of Cerebral Hemorrhage in China (2019) "Chinese Journal of Neurology" 2019, Volume 52, Issue 12, Pages 994-1005, leave a message here

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